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Centers for Disease Control and Prevention

Indicator Definitions - Mental Health

At least 14 recent mentally unhealthy days among women aged 18-44 years
Category: Mental Health
Demographic Group: Women aged 18-44 years.
Numerator: Female respondents aged 18-44 years who reported that their mental health was not good for 14 or more days in the past month.
Denominator: Female respondents aged 18-44 years who reported the number of days in the past month when their mental health was not good including none (excluding unknowns and refusals).
Measures of Frequency: Crude annual prevalence and 95% confidence interval, weighted using the BRFSS methodology (to compensate for unequal probabilities of selection, and adjust for non-response and telephone non-coverage); and by demographic characteristics when feasible.
Time Period of Case Definition: Previous 30 days.
Background: Mental health conditions, including depression and anxiety, are common among pregnant, postpartum, and non-pregnant women of reproductive age.1,2,3 Poor mental health may adversely  affect women’s family relations, social life and their ability to function at school or work.4 Poor mental health is associated with substance use and may put women at risk for future chronic disease, such as diabetes and heart disease.5,6. Poor mental health may adversely impact pregnancy, maternal infant bonding, maternal functioning, and infant and child health and development.1,7
Significance: Research has shown that poor mental health is a major source of distress, disability, and social burden.8   Furthermore, poor mental health can interfere with social functioning and negatively impact physical well-being as well as the practice of health-promoting behaviors.9
Limitations of Indicator: Reliability of data on the number of poor mental health days is currently not known.  However, the measure has been shown to be moderately valid.10  There are other age group definitions recognized for “reproductive age” but these measurements will consistently use the age range of 18-44 years.
Data Resources: Behavioral Risk Factors Surveillance System (BRFSS).
Limitations of Data Resources: As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).  In an effort to address some of these potential concerns, BRFSS began including cell phone only users in the 2011 data collection.  Due to changes in sampling and weighting methodology, 2011 is a new baseline for BRFSS, and comparisons with prior year data are inappropriate.
Related Indicators or Recommendations: None.
Related CDI Topic Area: Reproductive Health
  1. O’Hara MW. Postpartum depression: what we know. Journal of clinical psychology. Dec 2009;65(12):1258-1269.
  2. Ko JY, Farr SL, Dietz PM, Robbins CL. Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005-2009. Journal of women’s health. Aug 2012;21(8):830-836.
  3. Farr SL, Bitsko RH, Hayes DK, Dietz PM. Mental health and access to services among U.S. women of reproductive age. American journal of obstetrics and gynecology. Dec., 2010;203(6):542 e541-549.
  4. Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12-4725. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.
  5. Le Strat Y, Dubertret C, Le Foll B.  Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States.  Journal of affective disorders. Dec 2011;135(1-3):128-38.
  6. Farr SL, Hayes DK, Bitsko RH, Bansil P, Dietz PM. Depression, diabetes, and chronic disease risk factors among US women of reproductive age. Preventing chronic disease. Nov 2011;8(6):A119.
  7. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. General hospital psychiatry. Sep-Oct 2009;31(5):403-413.
  8. Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. 1996. Boston:  Harvard University Press.
  9. Surgeon General of the United States. Mental health: a report of the Surgeon General. 1999.  http://www.surgeongeneral.gov/library/mentalhealth/home.html
  10. Nelson DE, Holtzman D, Bolen J, et al. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Soc Prev Med 2001; 46 Suppl 1: S3-S42.

 

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Postpartum depressive symptoms
Category: Mental Health
Demographic Group: Women aged 18-44 years who have had a live birth.
Numerator: Respondents who reported that they felt down, depressed, or hopeless, often or always after their most recent live birth.
Denominator: Respondents who reported that they felt down, depressed, or hopeless never, rarely, sometimes, often, or always after delivery of their most recent live birth (excluding unknowns and refusals).
Measures of Frequency: Crude prevalence and 95% confidence interval, weighted using the PRAMS methodology (to compensate for unequal probabilities of selection, and adjust for non-response and mail/telephone non-coverage); and by demographic characteristics when feasible.
Time Period of Case Definition: Since the most recent live birth.
Background: Depressive disorders after delivery range from “baby blues”, which occur within the first several weeks after delivery, to depression of postpartum onset (postpartum depression), which is more severe, requires treatment, and can manifest up to one year after delivery.1  Postpartum depression is estimated to affect 14-15% of mothers, and has been shown to have an adverse effect on marital relationships and mother-infant bonding, and can contribute to unfavorable parenting and infant health practices.2-8
Significance: Depressive disorders generally have high recurrence rates, and previous depression and/or postpartum depression is predictive of depression during and after subsequent pregnancies.9   Screening for depression has been shown to be simple and safe, and various treatments are available.10  Identifying high risk women in the preconception period may prevent the emergence of depressive disorders during pregnancy and postpartum.  Recommended screening for depression during well-baby visits in the postpartum period is also being considered by the American Academy of Pediatrics.11
Limitations of Indicator: It is not possible to distinguish preexisting depressive symptoms from those that manifested after delivery.  This indicator represents self-reported depressive symptoms only and cannot be used to determine actual depression status.  Various similar tools assessing self-reported depressive symptoms including feelings of being down depressed, sad, or hopeless, have been recommended for depression case-finding.9   Sensitivity measures for these tools is generally high with moderate to high specificity measures.12-14  The response option “slowed down” was excluded from the case definition as this experience may be common among new mothers due to lack of appropriate rest.  The measure for this indicator is a new item on the PRAMS Phase 6 questionnaire, which was implemented in 2009.  There are other age group definitions recognized for “reproductive age” but these measurements will consistently use the age range of 18-44 years.
Data Resources: Pregnancy Risk Assessment Monitoring System (PRAMS).
Limitations of Data Resources: PRAMS data is only collected from women who delivered a live-born infant, not all women of reproductive age, and from 40 states and one city, not the entire US.  PRAMS data are self-reported and may be subject to recall bias and under/over reporting of behaviors based on social desirability.   While most self-report surveys such as PRAMS might be subject to systematic error resulting from non-coverage (e.g. lower landline telephone coverage due to transition to cell phone only households or undeliverable addresses), nonresponse (e.g. refusal to participate in the survey or to answer specific questions), or measurement bias (e.g. recall bias), PRAMS attempts to contact potential respondents by mail and landline/cell telephone to increase response rates.  Another limitation is that women with fetal death or abortion are excluded.  PRAMS estimates only cover the population of residents in each state who also deliver in that state; therefore, residents who delivered in a different state are not captured in their resident state.
Related Indicators or Recommendations: None.
Related CDI Topic Area:  
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), Text Revision. Washington, DC: American Psychiatric Publishing, Inc; 2000.
  2. Dietz PM, Williams SB, Callaghan WM, et al. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry 2007;164:1515-20.
  3. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes. Rockville, MD: Agency for Healthcare Research and Quality; 2005. Evidence report/technology assessment 119; AHRQ publication 05-E006-2.
  4. Chung EK, McCollum KF, Elo IT, et al. Maternal depressive symptoms and infant health practices among low-income women. Pediatrics 2004; 113:e523-e529.  http:www.pediatrics.org/cgi/content/full/113/6/e523.
  5. Galler JR, Harrison RH, Ramsey F. Bed-sharing, breastfeeding and maternal moods in Barbados. Infant Beh Dev 2006; 29:526-34.
  6. Leiferman J. The effect of maternal depressive symptomatology on maternal behaviors associated with child health. Health Educ Behav 2002; 29:596-607.
  7. McLearn KT, Minkovitz CS, Strobino DM, et al. Maternal depressive symptoms at 2 to 4 months post partum and early parenting practices. Arch Pediatr Adolesc Med 2006;160:279-84.
  8. McLennan JD, Kotelchuck M. Parental prevention practices for young children in the context of maternal depression. Pediatrics 2000; 105:1090-95.
  9. Frieder A, Dunlop AL, Culpepper L, et al. The clinical content of preconception care: women with psychiatric conditions. Am J Obstet Gynecol 2008; 199:(6 Suppl B):S328-32.   http://www.ajog.org/issues/contents?issue_key=S0002-9378%2808%29X0011-0
  10. U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. May 2002. Agency for Healthcare Research and Quality. http://www.ahrq.gov/clinic/3rduspstf/depression/depressrr.htm#scientific.
  11. Chaudron LH, Szilagyi PG, Campbell AT, et al. Legal and ethical considerations: risks and benefits of postpartum depression screening at well-child visits. Pediatrics 2007;119:123-28.
  12. Whooley MA, Avins AL, Miranda J, et al. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997; 12:439-445.
  13. Beck CT, Gable RK. Comparative analysis of the performance of the Postpartum Depression Screening Scale with two other depression instruments. Nurs Res 2001;50:242-50.
  14. Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care 2003; 41:1284-92.


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Recent mentally unhealthy days among adults aged ≥ 18 years
Category: Mental Health
Demographic Group: Resident persons aged ≥18 years.
Numerator: Sum of the number of days during the previous 30 days for which respondents aged ≥18 years report that their mental health (including stress, depression, and problems with emotions) was not good.
Denominator: Total number of respondents aged ≥ 18 years who report >=0 days during the previous 30 days for which their mental health was not good (excluding unknowns and refusals).
Measures of Frequency: Mean number of mentally unhealthy days during the previous 30 days — crude and age-adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 91) with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition: Previous 30 days.
Background: In 2009, the mean number of mentally unhealthy days (days when mental health was not good) during the previous 30 days was 3.5.2  This is the best available measure of population mental health.
Significance: Poor mental health interferes with social functioning, is associated with health behavior, and should be monitored as an overall indicator of chronic disease burden.3 Recent mentally unhealthy days is used with recent physically unhealthy days to estimate the mean number of unhealthy days (days with impaired physical or mental health) during the previous 30 days — a summary measure of population health.3
Limitations of Indicator: Although this indicator is based on self-assessment, it has been demonstrated to have good reliability, validity, and responsiveness.
Data Resources: Behavioral Risk Factor Surveillance System (BRFSS).
Limitations of Data Resources: As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).  In an effort to address some of these potential concerns, BRFSS began including cell phone only users in the 2011 data collection.  Due to changes in sampling and weighting methodology, 2011 is a new baseline for BRFSS, and comparisons with prior year data are inappropriate.
Related Indicators or Recommendations: None.
Related CDI Topic Area:  
  1. Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Healthy People Statistical Notes, no. 20. Hyattsville, Maryland: National Center for Health Statistics. January 2001. http://www.cdc.gov/nchs/data/statnt/statnt20.pdf.
  2. Centers for Disease Control and Prevention. Health-Related Quality of Life, Surveillance and Data.  http://www.cdc.gov/hrqol/data/tables/table3a.htm.  (27 November 2013).
  3. Centers for Disease Control and Prevention. Measuring Healthy Days. Atlanta, Georgia: CDC, November 2000.

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